Dear Patient,

Federal regulations require that we inform you in advance of the date of your procedure that you have the right to enter into an Advance Directive which is a written statement of your instructions and directions for health care in the event of your future decision making incapacity. An advance directive may include a proxy directive or an instruction directive, or both (N.J.A.C. 8:43 A-1.3).
Should you currently have an Advance Directive or wish to enter into one, we are obligated to inform you of our policies regarding Advance Directives:

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1. Centennial Surgery Center is a “Full Code” facility. By this we mean that every medical intervention available to us will be used to insure that your procedure has a successful outcome including any and all available resuscitative measures in the case of a medical emergency.

2. We request that all patients who have executed an “Advance Directive” inform us of this fact as soon as possible. Upon notification we will explain our “Full Code” policy in more depth and gain a better understanding of the directives that you have stipulated in the event of a medical emergency.

3. Patients who have been informed of our “Full Code” policy but still elect to have their procedure performed at Centennial will be asked to sign a DNR (Do Not Resuscitate) waiver on the day of their procedure acknowledging that they have waived this advance directive. This form will become a permanent part of their record at Centennial.

4. Patients who have executed an “Advance Directive” which include directives that conflict with Centennial’s “Full Code” policy may at anytime decide to cancel their procedure and have it rescheduled at a facility of their choice. This includes revoking any waiver previously signed.

5. We request that all patients who have executed an “Advance Directive” bring a copy of the document with them on the day of their procedure so that we can make it a part of your permanent record at Centennial.